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Welcome to Crash Course Economics, I'm Adriene Hill.
欢迎收看经济速成班，我是埃德因·希尔。
I'm Jacob Clifford. Today we're going to talk about the economics of healthcare.
我是雅各布·克利福德。我们今天将要讲医疗保健经济学。
Healthcare is different than some of the other markets we've talked about.
医疗保健市场不同于我们讨论过的其他市场。
If you're having a heart attack, you're not going to shop around for the hospital with the best prices.
如果你心脏病发作，就不会去医院货比三家选最便宜的了。
And a hospital emergency room isn't going to wait for your credit card to go through before they treat you.
而且医院的急诊室也不会等到你的信用卡通过后才给你治疗。
But we're getting ahead of ourselves. Let's get started.
但我们想得太超前了。现在开始讨论吧。
For a lot of reasons, healthcare is different than the other markets we've talked about.
因为许多原因，医疗保健不同于我们讨论过的其他市场。
First, you never know when you're gonna need it.
首先，你永远不知道什么时候需要它。
It's kinda hard to plan to fall off your bike and break your arm.
计划从自行车上摔下来折断胳膊似乎有点儿困难。
And after you break your arm, that visit to the emergency room?
你在胳膊折断后会去急诊室吗？
It's gonna be expensive. That's why we have health insurance, whether it's private or public.
它的代价会很昂贵。这就是为什么我们有私人或公共健康保险。
Private insurers periodically collect money in the form of premiums paid by individuals or their employers.
私人保险公司以个人或雇主支付保险费的形式定期筹钱。
Public insurance programs collect money from tax-payers.
公共保险项目从纳税人那里筹钱。
You'll hear some countries have free healthcare, but it's not free, they're paying for it.
你会听到一些国家有免费医疗，但它不是免费的，有人正在为它买单。
Either directly through insurers or through taxes.
要么直接通过保险公司，要么通过税收。
Let's work out all the details in the Thought Bubble.
我们在“ Thought Bubble”里讨论一下细节。
So Canada has a public health system where the government funds healthcare for everyone through taxation.
加拿大有一个公共卫生体系，政府通过税收筹钱为每个人提供医疗保健。
Doctors offices tend to be private businesses that get paid directly by the government;
医生办公室往往是由政府直接买单的私营企业；
but hospitals and operating tables are public property and hospital staff are public employees, sort of like public schools.
但是医院和手术台是公共财产，医院员工是公共雇员，有点儿像公立学校。
This is often called a single payer system since the government is doing most of the paying.
这通常被称为单一付款人系统，因为政府支付大部分费用。
Canadians have to pay for prescription drugs, eyeglasses, and dental care themselves
加拿大人必须自己支付处方药、眼镜和牙科护理费用，
or get them through supplemental private insurance.
或者通过补充私人保险来买单。
Now France technically doesn't have the single payer system
严格根据法律意义来讲，法国没有单一付款人系统，
because healthcare providers are paid through several non-profit insurance funds.
因为医疗保健提供者的服务费用是由几个非盈利保险基金来支付的。
All citizens are required to get health insurance and they're free to choose their doctor.
所有公民都必须参与医疗保险，他们可以自由选择医生。
Unlike Canada, most French providers, including hospitals, are private businesses.
与加拿大不同，医院在内的大多数法国医疗提供者都是私人企业。
The U.K. is different still.
英国也不同。
It has a socialized healthcare system which is funded and controlled by the government and taxes.
它有一个由政府和税收提供资金和控制的社会化医疗体系。
The majority of doctors, specialists and hospitals are all paid by the government, not insurance companies.
大多数医生、专家和医院都由政府，而不是保险公司付钱。
Today, the U.S. has a little of everything.
如今，美国的医疗保健体系兼而有之。
Almost all providers: hospitals, clinics and doctor's practices are private firms.
几乎所有的医疗提供者：医院、诊所和医生工作室都是私人机构。
Most households with adults under 65 are covered by private insurance;
大多数65岁以下的成年人都有私人保险；
either through their employers or through individual policies.
它们要么通过雇主缴纳，要么通过个人险缴纳。
But the US has a single payer system for those over 65 and those below the poverty line.
但美国还有一个针对65岁以上和贫困线以下的人群的单一付款人系统。
Medicare is a taxpayer funded public insurer that pays providers to care for seniors
医疗保险是由纳税人资助的公共保险，为老年人提供医疗服务，
and Medicaid is a similar program for low-income households.
而医疗补助是一个针对低收入家庭的类似项目。
Oh, and the US also has a small, UK-style system with government-run hospitals
哦，美国还有一个英式的官办小型医院系统，
and government employee doctors, but it's only for veterans and it's called the VA.
它由政府雇佣医生，但只针对退伍军人，叫做退伍军人管理局。
Thanks Thought Bubble.
感谢“Thought Bubble”。
So, let's get down to some numbers.
我们来看一些数据。
Economists evaluate the effectiveness of a healthcare system on three criteria: access, cost and quality.
经济学家评估医疗保健系统的有效性依靠三个标准：准入、成本和质量。
According to the Census Bureau,
根据人口普查局的数据，
in 2014 10.4% of Americans didn't have health insurance coverage, down from 13.3% in 2013.
2014年，10.4%的美国人没有医疗保险，低于2013年的13.3%。
Two thirds of Americans had health insurance through a private insurer.
三分之二的美国人通过私人保险公司获得医疗保险。
The vast majority got coverage through their employer and the rest bought individual plans.
绝大多数人由雇主缴纳保险，其余的人购买的是个人保险。
About a third of Americans had health insurance through a taxpayer-funded government insurance plan,
大约三分之一的美国人通过纳税人出资的政府保险计划购买了医疗保险，
like Medicare, Medicaid, the VA, and healthcare for active duty military and their families.
比如医疗保险、医疗补助、VA、现役军人及其家属的医疗保健。
So 2/3 plus 1/3 plus 10% uninsured adds up to more than 100%.
所以2/3+1/3 +没有保险的10%，总数超过了100%
That's because someone who switches from public insurance to private insurance gets counted in both numbers.
这是因为从公共保险转向私人保险的人被计算了两次。
That's just the way the census does it.
人口普查就是这么做的。
Let's talk a little about the uninsured.
我们来谈谈没有保险的人。
Compared with the general population,
与一般大众相比，
people without insurance tend to be somewhat younger, earn less and be more racially diverse.
没有保险的人往往更年轻、工资更少、种族更多元化。
Because Medicaid covers people below or near the poverty line, the uninsured are usually not completely destitute.
因为医疗补助能覆盖生活在贫困线以下或接近贫困线的人，没有医疗保险的人通常并不完全贫困。
They often work a part-time or low wage job, which puts them above the Medicaid threshold,
他们经常做兼职或低工资的工作，这让他们超出了医疗补助的门槛，
but their employers may not offer insurance to part-time workers.
但他们的雇主可能不会为兼职员工提供保险。
If an uninsured person gets sick or gets hit by a bus,
如果没有保险的人生病或被公共汽车撞倒，
they can easily get stuck with six figures of medical bills.
那么他们很容易被六位数的医药费困住。
And those unpaid medical expenses drive up costs for everybody.
这些未支付的医疗费用增加了每个人的费用。
This brings us to the cost of healthcare. Good news, Americans: we're number one!
这涉及到了医疗成本。好消息，美国人：我们第一！
Well, actually it's not that great.
但这不是好消息。
In 2012, the U.S. on average spent 8, 745 dollars per person on healthcare.
2012年，美国人均医疗支出为8745美元。
Other rich countries like Switzerland and Norway spent a little over 6,000 dollars
瑞士和挪威等其他富裕国家的支出仅为6000多美元。
and countries like Germany, France, the U.K., and Japan spent in the 3-5,000 dollars range.
德国、法国、英国、日本等国家的支出在3000到5000美元之间。
So the U.S. is spending twice as much per person as most other developed countries.
因此，美国人均医疗支出是其他大多数发达国家的两倍。
Put another way, the U.S. spent the same share of GDP just on Medicare
换句话说，美国医疗保险支出占GDP的比例
as most countries spend to cover their entire population.
与大多数国家全部人口的支出比例相当。
So why does the U.S. spend so much more than other countries?
那么，美国的支出为什么比其他国家多得多呢？
Well, some argue that it's due to the high quantity of care per person.
有些人认为这是由于每个人都有大量的护理。
Since insurance companies, rather than patients, pay providers,
因为保险公司而非病人支付医疗提供者费用，
patients might want more care, like tests, procedures, and treatments than necessary.
因此病人可能想要更多的照顾，比如一些非必要的测试、程序和治疗。
It's like an all you can treat buffet.
就像你吃自助餐一样。
You know you shouldn't go back for that fourth General Tso x-ray, but it's just so delicious.
你知道自己不应该回去第四次做X射线检查了，但它就像左宗棠鸡一样诱人。
The RAND Health Insurance Experiment a few decades ago found that
几十年前，兰德健康保险实验发现
requiring patients to pay for a portion of their healthcare costs deters them from over-consuming healthcare.
要求患者支付一部分医疗费用，会阻止他们过度消费医疗保健。
That's one reason that in the U.S., many insurance plans have deductibles,
这就是美国许多保险计划都有免赔额的一个原因，
a form of cost sharing where the patients is required to pay a part of the cost before the insurance kicks in.
免赔额是一种费用分摊形式，要求患者在保险生效前支付一部分费用。
Many economists say prices are also a problem.
许多经济学家说，价格也是一个问题。
In most other countries, insurers pay between 200 dollars and 400 dollars for an MRI.
在大多数其他国家，保险公司为一次核磁共振成像支付200到400美元。
In the U.S., the price is around 1,500 dollars and it's not like the U.S. MRI machines are somehow better.
在美国，它的价格在1500美元左右，而且美国的核磁共振机不见得更好。
They're exactly the same machines.
它们是完全相同的机器。
And you can go down the list of treatments and procedures,
你可以减少治疗和程序的清单，
and in nearly every case, U.S. providers are being paid three, four, five times more.
但在几乎所有的情况下，支付给美国医疗提供者的费用是三倍、四倍、五倍之多。
This is because the U.S. doesn't have a unified system
这是因为美国没有统一的体系
that can aggressively negotiate with doctors, pharmaceutical companies, and other providers.
可以与医生、制药公司和其他供应商积极协商。
They point out that Medicare and Medicaid often get a significant discount compared to small insurers.
他们指出，与小型保险公司相比，医疗保险和医疗补助通常会得到很大的折扣。
Another reason for the high cost is the blizzard of paperwork
造成高成本的另一个原因是大量的文书工作，
generated by the interaction between dozens of insurers and thousands of providers.
它由数十家保险公司和数千家医疗提供者的互动产生。
Both the insurer and the provider have to employ a team of unhappy people in cubicles
保险公司和医疗提供者都必须在隔间里雇佣一群不快乐的人
to haggle over the reimbursement rate of an appendectomy.
争论阑尾切除术的报销率。
These teams add to the administrative cost of healthcare.
这些团队增加了医疗管理成本。
So which problem is driving healthcare costs?
那么，什么问题推高了医疗成本呢？
Quantity, price, administrative costs?
数量、价格还是管理成本？
When you dig into the numbers, the U.S. consume a pretty high quantity of tests and treatments per person.
当你深入研究这些数据时，会发现每个美国人都要进行大量的测试和治疗。
But it's not radically higher than most other countries.
但它的费用并不比大多数其他国家高。
And several countries, like Germany, do even more.
德国等几个国家甚至更多。
Likewise, the U.S. administrative costs are also higher,
同样的，美国的管理成本也更高，
since a lot of countries drastically reduce their billing paperwork with a universal insurer.
因为许多国家都用通用的保险公司大幅减少文书工作。
But that cost explains only about 10-20% of the cost difference.
但这一成本仅能解释10-20%的成本差异。
Most of the difference comes from the fact that U.S. providers are paid much higher prices than their counterparts in other countries.
差异的主要原因在于，美国医疗供应者的费用比其他国家供应商的费用高很多。
Okay, let's talk quickly about quality.
让我们快点儿谈谈质量。
There are a lot of ways to measure the quality of a country's healthcare system.
衡量一个国家医疗体系质量的方法有很多。
Let's look at a few different metrics.
我们来看几个不同的指标。
According to the Kaiser Family Foundation,
根据凯撒家庭基金会的数据，
the U.S. has higher rates of hospital admissions for preventable conditions,
美国在可预防疾病方面的住院率较高，
and it has high rates of medical, medication and lab errors.
同时它还有高比例的医疗、药物和实验室错误。
The U.S. does stock up pretty well in terms of diagnosing and successfully treating conditions like heart disease and some types of cancer.
在诊断和成功治疗心脏病和某些癌症等疾病方面，美国确实做得很好。
But remember, spending per capita is much higher in the U.S. than the rest of the world.
但要记住，美国的人均支出远远高于世界其他地区。
Reforming is difficult thanks to something called the Iron Triangle.
改革之所以困难，是因为所谓的“铁三角”。
The Iron Triangle is a section of the western Atlantic Ocean
铁三角是西大西洋的一部分，
where ships and planes are frequently spirited away by extraterrestrials.
在那里，船只和飞机经常被外星人带走。
Sorry, I'm terrible at triangles. That's the Bermuda Triangle.
对不起，我对三角不在行，这应该是百慕大三角。
The Iron Triangle refers to the mutually beneficial relationship between members of Congress, government bureaucrats and lobbyists.
“铁三角”指的是国会议员、政府官员和说客之间的互利关系。
Bureaucrats want to protect their funding and jobs,
官僚们想要保护他们的资金和工作，
Congressmen want to get reelected, and lobbyists want to advance the interests of their clients.
国会议员想要连任，说客想要提高他们客户的利益。
And they all end up working toward policies that maintain the status quo
他们最终都致力于维持现状的政策
and aren't necessarily in the best interest of the people. But they're not worthless.
这些政策并不一定符合人们的最大利益，但也不是一文不值。
The Iron Triangle got together in 2010, and the U.S. government passed the Affordable Care Act, sometimes called ObamaCare.
铁三角在2010年合并，美国政府通过了平价医疗法案，有时也被称为奥巴马医改。
This stab at reforming the American healthcare system has been controversial to say the least.
不夸张地说，这场美国医疗体系的改革尝试是有争议的。
Let's take a look at what the law does and doesn't do.
我们来看看奥巴马医改允许什么，禁止什么。
ObamaCare didn't set up a U.K. style system, where hospitals are public property, and doctors are public employees.
奥巴马医改没有建立英式医疗体系，即医院是公共财产，医生是公共雇员。
It also didn't establish a universal public insurance system, like expanding Medicare to everyone.
它也没有建立一个全民公共保险制度，比如将公共保险扩大到每个人。
Instead, the Affordable Care Act tries to increase health coverage
相反，《平价医疗法案》通过要求私人健康保险公司为所有申请人投保
by requiring private health insurers to insure everyone who applies,
来试图增加医疗保险的覆盖面，
charge the same premiums to people of the same age, and cover pre-existing conditions.
对相同年龄的人收取相同的保费，并覆盖已存在疾病的人。
To prevent otherwise healthy people from only buying health insurance when they get sick,
为了防止健康的人只在生病时购买健康保险，
it requires everyone to obtain health insurance or pay a fee.
它要求每个人都缴纳医疗保险或支付费用。
The law also subsidizes health insurance premiums for those who can't afford to pay market rates.
该法案还为那些支付不起市场价格的人提供医疗保险费补贴。
So that's ObamaCare's supposed to do. Is it working?
这就是奥巴马医改原有的作用，它起作用了吗？
Well, it has reduced the number of Americans without insurance.
它减少了没有参保的美国人数量。
So access seems to have improved.
因此方案似乎有改善效果。
The Affordable Care Act also has provisions meant to deal with cost, and that's a little more difficult to assess.
《平价医疗法案》中也有应对成本的条款，这就有点儿难以评估了。
The act rewards doctors for cutting costs and requires greater price transparency.
该法案奖励医生削减成本，并要求提高价格透明度。
It also mandates a move to electronic record keeping.
它还要求采取电子记账的方式。
As far as improving quality goes, it's probably too early to tell.
至于提高质量，现在说还为时过早。
In the end, the economic debate over healthcare
最终，关于医疗保健的经济辩论
is just like the debate over other topics we've covered in Crash Course Economics
就像我们在经济速成班讨论的其他话题
like price controls, climate change, and equality in education.
如价格控制、气候变化和教育平等一样。
The recurring question is when, if ever,
如果有反复出现的问题，它是指
should the government get involved to help markets achieve the most effective, efficient, and fair outcome?
政府应该什么时候参与，从而帮助市场实现最有效、最公平的结果。
ObamaCare reflects people's attitude towards government and capitalism.
奥巴马医改反映了人们对政府和资本主义的态度。
Americans don't fully trust either one of them.
美国人并不完全信任它们中的任何一个。
Healthcare reforms have left private insurers and providers in place, but at the same time increased regulation.
医疗改革已经让私营保险公司和医疗服务提供商就位，但同时监管也在加强。
Insurers are now required to do things they wouldn't normally do, like cover people with pre-existing conditions.
保险公司现在被要求做一些他们通常不会做的事，比如为已存在疾病的人投保。
So that's the American healthcare system, which is weird, and expensive, and necessary.
这就是美国医疗系统，很奇怪、很昂贵，也很必要。
That's also the end of our textbook economics episodes.
它也是我们经济学教科书部分的结束。
So I'm moving to Canada to write a textbook and enjoy some of that sweet, sweet subsidized healthcare.
我要搬到加拿大去写一本教科书，并享受那种甜蜜的补贴医疗。
And I'm gonna stick around and talk about the economics of things like immigration, and social security, and happiness.
我将继续坚持谈论经济问题，比如移民、社会保障和幸福。
Thanks for watching. She'll see you next week.
感谢您的收看，她将下周见。
Thanks for watching Crash Course Economics.
感谢您收看经济速成班。
It's made with the help of all these awesome people.
它是由这些好心人帮助制作的。
You can help keep Crash Course free for everyone forever by supporting at Patreon.
你可以通过支持Patron上的节目帮助速成班永远免费对所有人开放。
Patreon is a voluntary subscription service, where you can support this show with a monthly contribution.
Patreon是个自愿订阅服务的平台，你可以每月捐助来支持该节目。
Thanks for watching. DFTBA.
感谢您的收看，别忘了做个了不起的人。
